Repetitive Blunt Trauma and Arterial Injury in the Hand.

INTRODUCTION/PURPOSE: Arterial injury in the hand is most often due to repetitive blunt trauma. Although not always associated with significant impairment, it may cause serious ischemic damage or considerable disability. As a cause of digital ischemia, the frequency of this disorder is widely under appreciated. This study reviews the clinical and angiographic features of this condition. MATERIALS/METHODS: An extensive literature review combined with the authors experience with arterial injury in the hand due to repetitive blunt hand trauma is summarized with emphasis on mechanisms of injury and pathologic changes to explain the angiographic findings and clinical presentations. RESULTS: Angiographic findings are related to severity of injury and underlying changes in the arterial wall. The clinical presentation varies from asymptomatic to digital necrosis and gangrene, related to severity of arterial injury, collateral circulation, and the highly variable arterial anatomy in the hand. CONCLUSION: Early recognition is important because compared to many other causes of digital ischemia in the upper extremities, traumatic arterial injury is frequently readily treatable. Angiographic findings and clinical presentation are often characteristic. The diagnosis should not be based on a clear history of repetitive hand trauma since the patient may be unaware of this occurrence.

Vascular Ultrasound and Noninvasive Physiological Testing for Peripheral Arterial Disease: Are These Tests Being Overused?

PURPOSE: To examine recent trends in the use of duplex ultrasound and noninvasive physiologic tests (NPTs) for determining the presence of peripheral arterial disease (PAD). METHODS: Medicare Part B databases for 2001-2013 were used. The two Current Procedural Terminology, version four codes for duplex ultrasound of lower-extremity arteries, and the three codes for NPTs of extremity arteries were selected. Procedure volumes of both types of examinations were determined, and utilization rates per 100,000 beneficiaries were calculated. Medicare specialty codes were used to determine what proportions were performed by the major specialty groups involved in these examinations: surgeons, cardiologists, radiologists, and primary care physicians (PCPs). RESULTS: Between 2001 and 2010 (the peak year), the total utilization rates per 100,000 of duplex ultrasound and NPTs increased by 94% and 84%, respectively. During the ensuing three years, small declines occurred in both. In 2013, utilization rates of both types of tests were far higher than they had been in 2001 (88% higher for duplex ultrasound; 63% higher for NPTs). From 2001 to 2013, use of duplex ultrasound increased 235% among cardiologists, 90% among surgeons, 76% among radiologists, and 53% among PCPs. Utilization rates of NPTs among surgeons were already high in 2001 and increased an additional 23% by 2013. The NPT utilization rates increased 180% among PCPs, 179% among cardiologists, and 61% among radiologists. CONCLUSIONS: During a period when little growth occurred in the incidence of PAD, sharp growth occurred in testing for the disease.

Middle aortic coarctation.

BACKGROUND: Middle aortic coarctation (MAC), a variant of middle aortic syndrome, is a rare entity with only ∼200 cases described in the literature. It classically presents with early onset and refractory hypertension, abdominal angina, and lower extremity claudication. Although endovascular repair has been described for focal stenoses, open bypass remains the standard to restore abdominal inflow and correct renovascular hypertension. METHODS: We describe an unusually late presentation of MAC in a 52-year-old man from El Salvador with refractory hypertension since age 8 requiring 5 antihypertensive medications. He presented with acute chest pain and severe hypertension. He denied mesenteric and peripheral vascular symptoms. Distal pulses were not palpable. Creatinine was 1.9 mg/dL (peak 4.0 mg/dL). Computed tomography angiography demonstrated coarctation of the descending thoracic aorta with extensive collateralization. RESULTS: After control of blood pressure, the patient's singular anatomy dictated a descending thoracic aorta-infrarenal aortic bypass using a 16-mm woven Hemashield tube graft via a left fifth-interspace anterolateral thoracotomy and left retroperitoneal incision. The graft was tunneled through the posterior left hemidiaphragm. Patient had excellent recovery, with decrease in antihypertensive medications (5 to 2), restoration of all distal pulses, and no neurologic complications. Postoperative creatinine was 0.9 mg/dL. CONCLUSIONS: MACs are rare entities with presentation usually in youth or adolescence, comprising only 0.5-2% of all aortic coarctation cases. Etiologies include congenital, acquired, inflammatory, and infectious causes. If untreated, most patients do not survive past the fourth decade because of the sequelae of renovascular hypertension including myocardial infarction, heart failure, intracranial hemorrhage, and aortic rupture. Depending on technical considerations, open surgical bypass remains the standard repair for MAC.

A validation study of the FocalPoint GS imaging system for gynecologic cytology screening.

BACKGROUND: Studies of the performance of the automated FocalPoint Guided Screening (FPGS) imaging system in gynecologic cytology screening relative to manual screening have yielded conflicting results. In view of this uncertainty, a validation study of the FPGS was conducted before its potential adoption in 2 large laboratories in Ontario. METHODS: After an intense period of laboratory training, a cohort of 10,233 current and seeded abnormal slides were classified initially by FPGS. Manual screening and reclassification blinded to the FPGS results were then performed. Any adequacy and/or cytodiagnostic discrepancy between the 2 screening methods subsequently was resolved through a consensus process (truth). The performance of each method's adequacy and cytodiagnosis vis-a-vis the truth was established. The sensitivity and specificity of each method at 4 cytodiagnostic thresholds (atypical squamous cells of undetermined significance or worse [ASC-US+], low-grade squamous intraepithelial lesion or worse [LSIL+], high-grade squamous intraepithelial lesion or worse [HSIL+], and carcinoma) were compared. The false-negative rate for each cytodiagnosis was determined. RESULTS: The performance of FPGS in detecting carcinoma, HSIL+, and LSIL+ was no different from the performance of manual screening, but the false-negative rates for LSIL and ASC-US were higher with FPGS than with manual screening. CONCLUSIONS: The results from this validation study in the authors' laboratory environment provided no evidence that FPGS has diagnostic performance that differs from manual screening in detecting LSIL+, HSIL+, or carcinoma.

Omega-3-enriched lipid emulsion for liver salvage in parenteral nutrition-induced cholestasis in the adult patient.

The intrahepatic cholestasis attributed to parenteral nutrition (PN) in the adult patient is relatively rare and usually occurs in patients receiving long-term PN. This article reports the first case of an adult patient with cholestatic PN-associated liver disease without sepsis who received almost all her nutrition requirements through PN. Administration of an ω-3-enriched lipid emulsion added to the PN regimen reversed cholestasis and demonstrated histologic improvement on serial liver biopsy. The patient had failed to respond to other modalities of treatment for this condition and was deeply jaundiced. Liver biochemistry profiles returned to baseline, and follow-up liver biopsy showed that cholestasis had resolved and that the only residual changes were mild portal inflammation with no histochemical or ultrastructural progression. The PN regimen for the patient was restored to provide total estimated energy requirements and remains the principle source of the patient's nutrition to date.

Colonoscopy Leads to A Diagnosis of A Jejunal Gastrointestinal Stromal Tumour (GIST).

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal (GI) tract, but are the least common of small intestinal malignant neoplasms. While GI bleeding is the most common clinical presentation of GISTs, intussusception and obstruction are uncommon, as GISTs rarely grow into the lumen. We describe an unusual case of a 50-year-old male who presented with intermittent obscure, overt GI bleeding requiring multiple hospital admissions and blood transfusions. His work-up included abdominal CT imaging, small bowel follow-through, gastroscopies, push enteroscopy, colonoscopies, and anterograde and retrograde double-balloon enteroscopies. Complicating his presentation were colonic angiodysplasias and the development of recurrent venous thromboembolism requiring anticoagulation. Within an hour after an apparently uncomplicated colonoscopy, he developed an acute abdomen secondary to a jejunal intussusception, which led to a laparoscopic small bowel resection and the diagnosis of a jejunal GIST. Given his GIST had no high-risk features, ongoing surveillance with abdominal CT imaging was arranged. This case illustrates the complex presentation and diagnostic difficulty of a jejunal GIST causing obscure, overt GI bleeding and this is the first reported case of a jejunal intussusception following colonoscopy. Due to its submucosal location, multiple endoscopic approaches had failed to diagnose the GIST prior to surgery.

Renal artery aneurysm and arteriovenous fistula associated with fibromuscular dysplasia: successful treatment with detachable coils.

Renal artery aneurysms are more common in patients with fibromuscular dysplasia (FMD). Although these aneurysms have traditionally been managed surgically, endovascular techniques are playing a larger role. Many treatment methods involve the use of stent-grafts to exclude the aneurysm or bare stents to protect the main renal artery while coil embolization is performed through the interstices. Herein, the authors present a patient with an arteriovenous fistula secondary to FMD that was managed entirely with use of detachable coils, which allowed preservation of the uninvolved renal parenchyma.

Doppler optical coherence tomography monitoring of microvascular tissue response during photodynamic therapy in an animal model of Barrett's esophagus.

BACKGROUND: Doppler optical coherence tomography (DOCT) is an imaging modality that allows assessment of the microvascular response during photodynamic therapy (PDT) and may be a powerful tool for treatment monitoring/optimization in conditions such as Barrett's esophagus (BE). OBJECTIVE: To assess the technical feasibility of catheter-based intraluminal DOCT for monitoring the microvascular response during endoluminal PDT in an animal model of BE. DESIGN: Thirteen female Sprague-Dawley rats underwent esophagojejunostomy to induce enteroesophageal reflux for 35 to 42 weeks and the formation of Barrett's mucosa. Of these, 9 received PDT by using the photosensitizer Photofrin (12.5 mg/kg intravenous), followed by 635-nm intraluminal light irradiation 24 hours after drug administration. The remaining 4 surgical rats underwent light irradiation without Photofrin (controls). Another group of 5 normal rats, without esophagojejunostomy, also received PDT. DOCT imaging of the esophagus by using a catheter-based probe (1.3-mm diameter) was performed before, during, and after light irradiation in all rats. RESULTS: Distinct microstructural differences between normal squamous esophagus, BE, and the transition zone between the 2 tissues were observed on DOCT images. Similar submucosal microcirculatory effects (47%-73% vascular shutdown) were observed during PDT of normal esophagus and surgically induced BE. Controls displayed no significant microvascular changes. CONCLUSIONS: No apparent difference was observed in the PDT-induced vascular response between normal rat esophagus and the BE rat model. Real-time monitoring of PDT-induced vascular changes by DOCT may be beneficial in optimizing PDT dosimetry in patients undergoing this therapy for BE and other conditions.

Follicular carcinoma of the thyroid with aggressive metastatic behavior in a pregnant woman: report of a case and review of the literature.

Distant metastases as initial presentation of follicular carcinoma of the thyroid is rare, especially in young patients. We report the clinical and pathological features of a 33-year old pregnant patient with follicular carcinoma of the thyroid who presented with widespread bone and lung metastases at the time of diagnosis. the resected tumor had a focal insular component that showed extensive vascular invasion spreading beyond the thyroid capsule, and was associated with widespread bone and lung metastases. Despite its aggressive behavior, the tumor had low mitotic activity and Ki-67 nuclear labeling index. tumor cells showed high microvascular density and down-regulation of E-cadherin, a calcium-dependent trans-membrane epithelial protein molecule known to promote intercellular adhesion. We suggest that architectural differentiation of the tumor and cell proliferation rate are not reliable markers of metastatic behavior in this particular thyroid neoplasm. Microvascular density and down-regulation of E-cadherin expression in the tumor should be included among histologic hallmarks of metastatic potential. the role of pregnancy in the aggressive behavior of this tumor is discussed along with a literature review.

Gastric calcifying fibrous tumor.

Intramucosal gastric tumours are most commonly found to be gastrointestinal stromal tumours or leiomyomas (smooth muscle tumours); however, a variety of other uncommon mesenchymal tumours can occur in the stomach wall. A rare benign calcifying fibrous tumour is reported and the endoscopic appearance, ultrasound findings and morphology are documented. A review of the literature found only two similar cases.

Capsule endoscopy findings in patients with established and suspected small-bowel Crohn's disease: correlation with radiologic, endoscopic, and histologic findings.

BACKGROUND: Little is known about the accuracy of capsule endoscopy (CE) in evaluation of small-bowel Crohn's disease. METHODS: Symptomatic eligible patients had ileocolonoscopy and biopsies from the terminal ileum, followed by small-bowel radiologic studies before CE. Endoscopic, radiologic, CE, and histologic findings were compared. Histology (terminal ileum biopsy specimens or a tissue sample after small-bowel resection) served as a criterion standard. RESULTS: Fifty-four patients were enrolled; 15 of the 54 patients were excluded from data analysis (critical small-bowel strictures, 14, identified on radiology; incomplete CE, 1). Data were analyzed for 39 patients. All patients had histologic evaluation of the small bowel. Final diagnosis of active small-intestine Crohn's disease was made in 29/39 patients (74.4%). When calculated, CE yielded a sensitivity and a specificity of 89.6% and 100.0%, respectively, and a positive predictive value and a negative predictive value of 100.0% and 76.9%, respectively, whereas small-bowel series were 27.6%/100.0% and 100.0%/32.3%. CONCLUSIONS: CE is more accurate in detecting small-bowel inflammatory changes suggestive of Crohn's disease than conventional studies. CE, combined with ileocolonoscopy, may be proposed as a first-line investigation of the small intestine in cases of uncomplicated known or suspected Crohn's disease.

Endoscopic Doppler optical coherence tomography in the human GI tract: initial experience.

BACKGROUND: Expanding the current endoscopic optical coherence tomography (OCT) system with Doppler capability may augment this novel high-resolution cross-sectional imaging technique with functional blood flow information. The aim of this feasibility study was to assess the clinical feasibility of an endoscopic Doppler OCT (EDOCT) system in the human GI tract. METHODS: During routine endoscopy, 22 patients were imaged by using a prototype EDOCT system, which provided color-Doppler and velocity-variance images of mucosal and submucosal blood flow at one frame per second, simultaneously with high-spatial-resolution (10-25 mum) images of tissue microstructure. The images were acquired from normal GI tract and pathologic tissues. OBSERVATIONS: Subsurface microstructure and microcirculation images of normal and pathologic GI tissues, including Barrett's esophagus, esophageal varices, portal hypertensive gastropathy, gastric antral vascular ectasia, gastric lymphoma, and duodenal adenocarcinoma, were obtained from 72 individual sites in vivo. Differences in vessel diameter, distribution, density, and blood-flow velocity were observed among the GI tissue pathologies imaged. CONCLUSIONS: To our knowledge, this is the first study to demonstrate the feasibility of EDOCT imaging in the human GI tract during routine endoscopy procedures. EDOCT may detect the different microcirculation patterns exhibited by normal and diseased tissues, which may be useful for diagnostic imaging and treatment monitoring.

Given capsule endoscopy in celiac disease: evaluation of diagnostic accuracy and interobserver agreement.

BACKGROUND AND AIMS: Capsule endoscopy (CE) has been increasingly used for diagnosing diseases of the small bowel. It is an attractive technique for assessing celiac disease (CD) because it is noninvasive and provides a close and magnified view of the mucosa of the entire small bowel. In this study, we evaluated the accuracy of CE and interobserver agreement in recognizing villous atrophy (VA) using histopathology as the reference. We also explored the extent of small bowel involvement with CD and the relationship between the length of the affected bowel and the clinical presentation. METHODS: Ten CD patients with histologically proven VA and the same number of controls were subjected to CE. Four, blinded to histology findings, investigators (two with and two without prestudy CE experience) were asked to diagnose VA on CE images. RESULTS: Based on assessment of all four investigators, the overall sensitivity, specificity, PPV, and NPV of CE in diagnosing VA were 70%, 100%, 100%, and 77%, respectively. The sensitivity and the specificity of the test was 100% when the reports of experienced capsule endoscopists only were analyzed. The interobserver agreement was perfect (kappa= 1.0) between investigators with prestudy CE experience and poor (kappa= 0.2) between the investigators who had limited prestudy exposure to CE. Celiac patients with extensive small bowel involvement had typical symptoms of malabsorption (diarrhea, weight loss) as opposed to mild and nonspecific symptoms in patients whose disease was limited to the proximal small bowel. CE was tolerated well by all study participants with 95% reporting absence of any discomfort. CONCLUSIONS: Although based on a small sample size, the study suggests that CE may be useful in assessing patients with CD. Familiarity with CE technology appears to be a critical factor affecting the accuracy of the test. Larger studies are warranted to more precisely define the advantages and limitations of CE in CD.

Malignant paraganglioma of the urinary bladder: Immunohistochemical study of prognostic indicators.

Using various immunohistochemical markers, the objective of our study was to assess whether correlation exists between growth potential of paraganglioma (pheochromocytoma) cells and formation of metastasis. The patient was a 28-yr-old man who presented with intermittent episodes of gross hematuria due to a mass in the urinary bladder. He had no constitutional symptoms to suggest paraganglioma. Histologic, immunohistochemical, and electron microscopic investigation of the surgically removed tissue proved that the tumor was a malignant paraganglioma with metastases in the regional lymph nodes. The immunohistochemical tests were not supportive of high cell proliferation index, indicating that metastases can develop in the absence of rapid multiplication of the tumor cells. Abnormalities in vascular architecture and marked expression of VEGF in the tumor cells may be regarded as prognostic signs to predict the formation of metastases.

Angiographic assessment of initial balloon angioplasty results.

PURPOSE: To determine the influence of three factors involved in the angiographic assessment of balloon angioplasty-interobserver variability, operator bias, and the definition used to determine success-on the primary (technical) results of angioplasty in the peripheral arteries. MATERIALS AND METHODS: Percent stenosis in 107 lesions in lower-extremity arteries was graded by three independent, experienced vascular radiologists ("observers") before and after balloon angioplasty and their estimates were compared with the initial interpretations reported by the physician performing the procedure ("operator") and an automated quantitative computer analysis. Observer variability was measured with use of intraclass correlation coefficients and SD. Differences among the operator, observers, and the computer were analyzed with use of the Wilcoxon signed-rank test and analysis of variance. For each evaluator, the results in this series of lesions were interpreted with three different definitions of success. RESULTS: Estimation of residual stenosis varied by an average range of 22.76% with an average SD of 8.99. The intraclass correlation coefficients averaged 0.59 for residual stenosis after angioplasty for the three observers but decreased to 0.36 when the operator was included as the fourth evaluator. There was good to very good agreement among the three independent observers and the computer, but poor correlation with the operator (P

Does whipworm increase the pathogenicity of Campylobacter jejuni? A clinical correlate of an experimental observation.

Campylobacter jejuni is a leading cause of acute diarrhea worldwide, usually mild and self-limiting. No adequate hypothesis has yet been formulated to explain why in an otherwise healthy host this infection is occasionally severe. In a pig model, C jejuni has been shown to be pathogenic only in the presence of swine whipworm. A human case of life-threatening C jejuni colitis leading to toxic megacolon and acute renal failure, associated with concomitant whipworm (Trichuris suis) ova in the feces, is reported. The potential of T suis to potentiate C jejuni in humans deserves further study.

In vivo Doppler optical coherence tomography of mucocutaneous telangiectases in hereditary hemorrhagic telangiectasia.

BACKGROUND: Hereditary hemorrhagic telangiectasia is characterized by mucocutaneous telangiectases and visceral arteriovenous malformations. Knowledge is limited concerning the development hemodynamics of mucocutaneous telangiectases. Doppler optical coherence tomography can demonstrate microvascular blood flow at flow rates as low as 20 microm/second, which is up to approximately 100 times more sensitive than Doppler US. The aims of this study were to collect in vivo Doppler optical coherence tomography images of mucocutaneous telangiectases and normal surrounding mucosa and skin, and to gain experience for an in vivo GI endoscopic study. It was hypothesized that visibly normal areas may have occult telangiectases and that mucocutaneous telangiectases that have bled may have a higher rate of blood flow than mucocutaneous telangiectases with no history of bleeding. METHODS: Twelve patients with hereditary hemorrhagic telangiectasia and mucocutaneous telangiectases were studied. Two to 3 visible mucocutaneous telangiectases on the digits, lips, and tongue were imaged with Doppler optical coherence tomography, along with visually normal surrounding areas at each site. The Doppler optical coherence tomography images were obtained in 0.5 second by using 1310 nm light. RESULTS: A total of 67 mucocutaneous telangiectases from the 12 patients were imaged (38 digit, 16 lip, 13 tongue). Blood flow was demonstrated within every mucocutaneous telangiectasis imaged. Doppler optical coherence tomography did not identify any abnormal vasculature within visually normal areas. Mucocutaneous telangiectases with a history of bleeding (n = 18) were situated closer to the surface, compared with mucocutaneous telangiectases with no bleeding history (n = 49), but there was no difference in the Doppler flow appearance. CONCLUSIONS: Visually normal areas in patients with hereditary hemorrhagic telangiectasia did not appear to have abnormal vasculature. Mucocutaneous telangiectases with a history of bleeding were more superficial but were otherwise similar to mucocutaneous telangiectases with no bleeding history.